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Technic of operation for varicose veins
TECHNIC OF OPERATION JOHN
E.
Associate in Anatomy,
FOR VARICOSE
SUMMERS, University
VEINS
M.D.* of South Dakota
Norwalk, Connecticut
T
foIIowing procedure has. been found to give very satisfactory res&s in cases of varicosities invoIving the greater and Iesser saphenous venous systems. The purpose of the operation is to remove the main trunk of the great saphenous vein (aIso the Iesser saphenous vein when it is invoIved) and communicating veins. Sclerosing chemicaIs are never empIoyed at any time. Preliminary Examination. The preIiminary examination incIudes the usua1, compIete physica examination and Iaboratory tests. Various tests previousIy empIoyed to determine competency of the valves of the great saphenous and communicating veins are not used. Varicose degeneration of veins is progressive and usuaIIy starts in the Ieg where hydrostatic pressure is highest. If anything is done at aI1, the patient shouId have the compIete operation in order to get the best resuIts. In cases of varicose veins which have been preceded by phlegmasia alba dolens the patency of the deep veins is tested by appIying an eIastopIast bandage to the Iower extremity and having the patient return in one week. WhiIe more serious pathoIogic conditions must be treated first, there are no contraindications to the remova of varicose veins by the method herein described. Preparation of the Extremity. The lower abdomen, pubis, groin and entire lower extremity are shaved, washed with green soap, water, ether and aIcoho1; both Iower extremities are so prepared if the operation is to be bilateral. Preoperative Medication. As the operation is performed under IocaI anesthesia, adequate preoperative medication is essentiaI to aIIay anxiety and prevent disHE
* Formerly Associate in Anatomy, 72
comfort. UsuaIIy s/4 gr. morphine suIfate and 145 to 3 gr. nembuta1 wiI1 keep the patient comfortabIe during the operation and prevent any unpIeasant memories. Preoperative Examination of Varicose Veins. The patient (dizzy from the medication) is assisted to stand up at the operating table whiIe the operator sits on the floor and studies the varicosities by observation and paIpation. The course of the greater saphenous vein is noted and buIbous diratations aIong its course are marked as probabIe incompetent communicating veins. Large, incompetent communicating veins produce paIpabIe defects in the deep fascia. Large coIIections of varicosities are marked for excision (the skin is scratched with a knife blade). Connections with the Iesser saphenous vein are noted and the condition of the Iesser saphenous venous system simiIarIy studied. Draping the Patient. In the femaIe a narrow, folded towe covers the genitalia and is taped anteriorIy and posteriorly; in the maIe the genitaIia are taped up on the abdomen out of the way. The groin and entire lower extremity is painted with antiseptic soIution and draped so that it wiI1 be avaiIabIe for operation; steriIe toweIs are wrapped around the foot. Operation in the Groin. The subcutaneous tissue in the groin over the fossa ovaIis is wideIy infiItrated with a I per cent soIution of novocain using spina needIes. The skin incision is made directly in the crease of the groin beginning about 155 inches media1 to the puIsations of the femoraI artery and extending 2 or 3 inches IateraIIy. (Fig. I.) By pIacing the incision high, one comes down directIy over the saphenofemora1 junction and the dissection of the veins is faciIitated. The incision is University
of South Dakota.
VOL. LXXVI,
No. I
Summers-Operation
FIG. I. Dissection of the veins at the saphenofemorat junction is facilitated by making the skin incision directly in the crease of the groin.
carried down immediateIy to the deep Iayer of the superficial fascia (continuation of Scarpa’s fascia from the Iower abdomen). There are no vesseIs of note between the skin and this deep Iayer of superficia1 fascia. The veins to be Iigated Iie beneath this Iayer of fascia. The deep Iayer of the superticia1 fascia is incised; one or more of the main tributaries to the termina1 saphenous vein are reveaIed by gentIe wiping with a gauze sponge. Dissection of the fossa ovaIis is carried out by the use of a pIain forceps and a curved KeIIy hemostat. One Iooks for the superficia1 inferior epigastric vein, superficia1 circumffex iliac vein, superficia1 externa1 pudenda1 veins (they may be dupIicated or tripIicated), IateraI superficia1 femora1 vein, media1 superficia1 femora1 vein and the great saphenous vein. The superficial externa pudenda1 artery passes mediaIIy over the termination of the great saphenous vein whiIe the deep externa1 pudenda1 artery passes mediaIIy beneath the termination of the great saphenous vein. These are smaI1 arteries which can cause troubIesome bleeding as they arise directly from the femorai artery. One obtains more
for Varicose
Veins
American
Journal
of Surgery
73
FIG. 2. The proximal stump of the great saphenous vein is ligated and suture-Iigated.
information and satisfaction if a11 veins in this area are dissected before they are cIamped, divided and Iigated. After a11 tributary veins have been dissected, anomalies noted and the femora1 vein demonstrated, the superficia1 veins are Iigated; the proxima1 stump (Fig, z) of the .great saphenous vein is tied and suture-ligated dista1 to the tie to prevent the ligature from bIowing off with an increase in intraabdomina1 pressure. The defect in the deep fascia, i. e., the fossa ovaIis, is cIosed with a figure-of-eight suture. (Fig. 3.) Stripping the Great Saphenous Vein. The great saphenous vein is stripped with a Mayo stripper as far down the Ieg as possibIe, quite often as far as the media1 maIIeolus. With adequate preoperative medication this stripping does not bother the patient to any serious degree. As the stripper meets an obstruction, the skin overIying with novocain the point is infiItrated and incised; the stripped segment of saphenous vein is brought out through the wound and the communicating vein causing the obstruction is cIamped, divided and Iigated. The stripping is then continued. Operation in the Leg. Of great importance is the remova of the main saphenous
74
Am&can
Journal
of Surgery
Summers-Operation
FIG. 3. The fossa ovalis is closed with a figure eight suture. The great saphenous vein in the thigh is stripped with a Mayo stripper until an obstruction is encountered. The skin over this point is infiltrated with novacain and a small incision is made. The saphenous vein is brought out through this incision and the communicating vein is isolated, clamped, divided and ligated. The saphenous vein is again threaded through the eye of the stripper and the stripping is continued.
vein and its incompetent communications in the Ieg. This is often the most timeconsuming and most negIected part of the operation. In the presence of much induration and scar tissue, such as resuIts from of the vein is heaIed uIcers, stripping impossibIe and excision of the varicosities through Iong skin incisions is necessary. (Fig. 4.) AI1 this is performed under IocaI anesthesia, The skin incision shouId be carried down directIy to the deep fascia, as the main trunk of the great saphenous vein Iies on this fascia. In the presence of Iarge varicosities one wiI1 be rewarded by finding severa1, Iarge communicating veins. If the Iesser saphenous vein is invoIved, the patient is turned over on his stomach and the vein is divided in the pop&teal fossa and eIsewhere if indicated. The Iesser saphenous vein is more anomaIous than the greater saphenous vein; one often has to incise the deep fascia in the popIitea1 fossa to reach the termina1 end of the Iesser saphenous vein.
for Varicose
Veins
JULY,
1948
FIG. 1. In uncomplicated cases the great snphenous vein can be stripped out, down to the internal malleolus by bringing the vein out through small skin incisions at the sites of the communicating veins, the communicating veins being divided and ligated. When have caused extensive scar degenerative changes tissue formation in the subcutaneous tissue of the leg, the veins are excised through long skin incisions.
It wiI1 be recaIIed that the saphenous nerve accompanies the great saphenous vein in the Ieg, the sura1 nerve accompanies the Iesser saphenous vein, and these nerves shouId not be Iigated or divided. Skin incisions are cIosed with interrupted cotton or silk sutures. Dressings. SteriIe gauze squares are taped over the wounds, cotton pads are pIaced over these and the entire Iower from the toes to above the extremity, groin, is snugIy wrapped with eIastopIast pressure dressing. Postoperative Care. The patient is waIked from the operating tabIe back to his room, waIks for five minutes every two hours for the foIIowing twenty-four hours and remains ambulatory thereafter. He is discharged home the day of the operation,
VOL. LXXVI.
No. I
Summers-Operation
or at his convenience, with instructions to remain active and return in ten days at which time bandages and skin sutures are removed. Pressure dressings are usuaIIy advised for severa weeks postoperativeIy to prevent edema. If the operation has been thorough, there will be no varicose veins of any importance Ieft in the extremity. If an incompetent communicating vein has been missed, it
for Varicose
Veins
A mcricnn Journd of Surgery
75
shsuId be excised under IocaI anesthesia. ScIerosing chemicaIs are never used at any time. The injection of a scIerosing chemica1 into a varicose vein produces not only a bad cosinetic resuIt due to the resuIting thrombosis, induration and pigmentation, but aIso is IiabIe to produce uIceration, phIebitis, emboIism and recurrence of the varicosity if there is any pressure on the vein from its deep connection.
E.
Associate in Anatomy,
FOR VARICOSE
SUMMERS, University
VEINS
M.D.* of South Dakota
Norwalk, Connecticut
T
foIIowing procedure has. been found to give very satisfactory res&s in cases of varicosities invoIving the greater and Iesser saphenous venous systems. The purpose of the operation is to remove the main trunk of the great saphenous vein (aIso the Iesser saphenous vein when it is invoIved) and communicating veins. Sclerosing chemicaIs are never empIoyed at any time. Preliminary Examination. The preIiminary examination incIudes the usua1, compIete physica examination and Iaboratory tests. Various tests previousIy empIoyed to determine competency of the valves of the great saphenous and communicating veins are not used. Varicose degeneration of veins is progressive and usuaIIy starts in the Ieg where hydrostatic pressure is highest. If anything is done at aI1, the patient shouId have the compIete operation in order to get the best resuIts. In cases of varicose veins which have been preceded by phlegmasia alba dolens the patency of the deep veins is tested by appIying an eIastopIast bandage to the Iower extremity and having the patient return in one week. WhiIe more serious pathoIogic conditions must be treated first, there are no contraindications to the remova of varicose veins by the method herein described. Preparation of the Extremity. The lower abdomen, pubis, groin and entire lower extremity are shaved, washed with green soap, water, ether and aIcoho1; both Iower extremities are so prepared if the operation is to be bilateral. Preoperative Medication. As the operation is performed under IocaI anesthesia, adequate preoperative medication is essentiaI to aIIay anxiety and prevent disHE
* Formerly Associate in Anatomy, 72
comfort. UsuaIIy s/4 gr. morphine suIfate and 145 to 3 gr. nembuta1 wiI1 keep the patient comfortabIe during the operation and prevent any unpIeasant memories. Preoperative Examination of Varicose Veins. The patient (dizzy from the medication) is assisted to stand up at the operating table whiIe the operator sits on the floor and studies the varicosities by observation and paIpation. The course of the greater saphenous vein is noted and buIbous diratations aIong its course are marked as probabIe incompetent communicating veins. Large, incompetent communicating veins produce paIpabIe defects in the deep fascia. Large coIIections of varicosities are marked for excision (the skin is scratched with a knife blade). Connections with the Iesser saphenous vein are noted and the condition of the Iesser saphenous venous system simiIarIy studied. Draping the Patient. In the femaIe a narrow, folded towe covers the genitalia and is taped anteriorIy and posteriorly; in the maIe the genitaIia are taped up on the abdomen out of the way. The groin and entire lower extremity is painted with antiseptic soIution and draped so that it wiI1 be avaiIabIe for operation; steriIe toweIs are wrapped around the foot. Operation in the Groin. The subcutaneous tissue in the groin over the fossa ovaIis is wideIy infiItrated with a I per cent soIution of novocain using spina needIes. The skin incision is made directly in the crease of the groin beginning about 155 inches media1 to the puIsations of the femoraI artery and extending 2 or 3 inches IateraIIy. (Fig. I.) By pIacing the incision high, one comes down directIy over the saphenofemora1 junction and the dissection of the veins is faciIitated. The incision is University
of South Dakota.
VOL. LXXVI,
No. I
Summers-Operation
FIG. I. Dissection of the veins at the saphenofemorat junction is facilitated by making the skin incision directly in the crease of the groin.
carried down immediateIy to the deep Iayer of the superficial fascia (continuation of Scarpa’s fascia from the Iower abdomen). There are no vesseIs of note between the skin and this deep Iayer of superficia1 fascia. The veins to be Iigated Iie beneath this Iayer of fascia. The deep Iayer of the superticia1 fascia is incised; one or more of the main tributaries to the termina1 saphenous vein are reveaIed by gentIe wiping with a gauze sponge. Dissection of the fossa ovaIis is carried out by the use of a pIain forceps and a curved KeIIy hemostat. One Iooks for the superficia1 inferior epigastric vein, superficia1 circumffex iliac vein, superficia1 externa1 pudenda1 veins (they may be dupIicated or tripIicated), IateraI superficia1 femora1 vein, media1 superficia1 femora1 vein and the great saphenous vein. The superficial externa pudenda1 artery passes mediaIIy over the termination of the great saphenous vein whiIe the deep externa1 pudenda1 artery passes mediaIIy beneath the termination of the great saphenous vein. These are smaI1 arteries which can cause troubIesome bleeding as they arise directly from the femorai artery. One obtains more
for Varicose
Veins
American
Journal
of Surgery
73
FIG. 2. The proximal stump of the great saphenous vein is ligated and suture-Iigated.
information and satisfaction if a11 veins in this area are dissected before they are cIamped, divided and Iigated. After a11 tributary veins have been dissected, anomalies noted and the femora1 vein demonstrated, the superficia1 veins are Iigated; the proxima1 stump (Fig, z) of the .great saphenous vein is tied and suture-ligated dista1 to the tie to prevent the ligature from bIowing off with an increase in intraabdomina1 pressure. The defect in the deep fascia, i. e., the fossa ovaIis, is cIosed with a figure-of-eight suture. (Fig. 3.) Stripping the Great Saphenous Vein. The great saphenous vein is stripped with a Mayo stripper as far down the Ieg as possibIe, quite often as far as the media1 maIIeolus. With adequate preoperative medication this stripping does not bother the patient to any serious degree. As the stripper meets an obstruction, the skin overIying with novocain the point is infiItrated and incised; the stripped segment of saphenous vein is brought out through the wound and the communicating vein causing the obstruction is cIamped, divided and Iigated. The stripping is then continued. Operation in the Leg. Of great importance is the remova of the main saphenous
74
Am&can
Journal
of Surgery
Summers-Operation
FIG. 3. The fossa ovalis is closed with a figure eight suture. The great saphenous vein in the thigh is stripped with a Mayo stripper until an obstruction is encountered. The skin over this point is infiltrated with novacain and a small incision is made. The saphenous vein is brought out through this incision and the communicating vein is isolated, clamped, divided and ligated. The saphenous vein is again threaded through the eye of the stripper and the stripping is continued.
vein and its incompetent communications in the Ieg. This is often the most timeconsuming and most negIected part of the operation. In the presence of much induration and scar tissue, such as resuIts from of the vein is heaIed uIcers, stripping impossibIe and excision of the varicosities through Iong skin incisions is necessary. (Fig. 4.) AI1 this is performed under IocaI anesthesia, The skin incision shouId be carried down directIy to the deep fascia, as the main trunk of the great saphenous vein Iies on this fascia. In the presence of Iarge varicosities one wiI1 be rewarded by finding severa1, Iarge communicating veins. If the Iesser saphenous vein is invoIved, the patient is turned over on his stomach and the vein is divided in the pop&teal fossa and eIsewhere if indicated. The Iesser saphenous vein is more anomaIous than the greater saphenous vein; one often has to incise the deep fascia in the popIitea1 fossa to reach the termina1 end of the Iesser saphenous vein.
for Varicose
Veins
JULY,
1948
FIG. 1. In uncomplicated cases the great snphenous vein can be stripped out, down to the internal malleolus by bringing the vein out through small skin incisions at the sites of the communicating veins, the communicating veins being divided and ligated. When have caused extensive scar degenerative changes tissue formation in the subcutaneous tissue of the leg, the veins are excised through long skin incisions.
It wiI1 be recaIIed that the saphenous nerve accompanies the great saphenous vein in the Ieg, the sura1 nerve accompanies the Iesser saphenous vein, and these nerves shouId not be Iigated or divided. Skin incisions are cIosed with interrupted cotton or silk sutures. Dressings. SteriIe gauze squares are taped over the wounds, cotton pads are pIaced over these and the entire Iower from the toes to above the extremity, groin, is snugIy wrapped with eIastopIast pressure dressing. Postoperative Care. The patient is waIked from the operating tabIe back to his room, waIks for five minutes every two hours for the foIIowing twenty-four hours and remains ambulatory thereafter. He is discharged home the day of the operation,
VOL. LXXVI.
No. I
Summers-Operation
or at his convenience, with instructions to remain active and return in ten days at which time bandages and skin sutures are removed. Pressure dressings are usuaIIy advised for severa weeks postoperativeIy to prevent edema. If the operation has been thorough, there will be no varicose veins of any importance Ieft in the extremity. If an incompetent communicating vein has been missed, it
for Varicose
Veins
A mcricnn Journd of Surgery
75
shsuId be excised under IocaI anesthesia. ScIerosing chemicaIs are never used at any time. The injection of a scIerosing chemica1 into a varicose vein produces not only a bad cosinetic resuIt due to the resuIting thrombosis, induration and pigmentation, but aIso is IiabIe to produce uIceration, phIebitis, emboIism and recurrence of the varicosity if there is any pressure on the vein from its deep connection.